“Some labs are seeing as much as an 85% drop in Blue Cross payments,” said Alice Carroll, president of Revenue Cycle Consultant, a firm specifically hired by labs to help enhance their billing systems and bolster their collection rates. “This is going to cause regional laboratories a big financial hardship … It’s something that we’re struggling with tremendously.”

Just ask the labs themselves. Fearing outright ruin, several regional laboratories have already raced to sue BCBS in a desperate attempt to reverse the BlueCard policy and escape the massive fallout that they otherwise expect. Their own panic devastatingly obvious, the plaintiffs warn of widespread casualties throughout the industry -- with “even the most distinguished reference labs” weathering painful blows, “hundreds of molecular and specialty labs” failing altogether and “the entire molecular industry” soon vanishing for good.

Since Bio-Reference never even bothered to mention the pesky BlueCard change to its investors, long accustomed to blowout financial results, the company better hope that it can somehow land enough extra business in Florida to offset the potential losses that it faces in elsewhere throughout the country.

By now, of course, Bio-Reference has already burst forth to hastily reaffirm its healthy projections and (well aware of the imminent release of this report) preemptively rule out the potential for any nasty surprises. Right after that urgent display of confidence, however, Bio-Reference proceeded to address questions posed by TheStreetSweeper with disturbing responses that – as illustrated throughout this article – often look thorny enough to undermine the credibility of both its guidance and its management alike.

For starters, Bio-Reference insisted that the company has in fact “commented generally about the change in the BlueCard plans” before now. Despite an extensive review of company-generated material directed at investors, however, TheStreetSweeper found no evidence – in press releases, conference calls, corporate presentations, etc. – that Bio-Reference had even uttered the phrase “BlueCard” at all. In the one document uncovered by TheStreetSweeper that did address this topic, the transcript of a speech given to an audience of laboratory executives, Bio-Reference CEO Marc Grodman seemed almost petrified of the new BlueCard restrictions and the resulting potential for outright disaster. He openly warned of the of the crushing damage that regional laboratories could expect unless they struck back against the so-called "Hezbollah tactics" and managed to block the crippling restrictions that they presently face.

Given that stark forecast, presented by its top executive less than a year ago, Bio-Reference looks dreadfully unprepared. When Bio-Reference calculated the hefty guidance that it just reaffirmed, the company apparently chose to disregard that treacherous hazard entirely.

“This is a complex issue which, for the most part, only became effective as of January 1, 2013,” Bio-Reference stated. “At this time, the company believes it is too early to ascertain potential impacts on its business.”

For starters, Bio-Reference knows perfectly well that the BCBS Assocation enacted that nationwide policy back in mid-October (or at least within weeks of that date), because Grodman actually warned other lab executives about the deadline -- almost six months in advance -- back when he delivered his informative speech. Just look at the evidence: "BlueCard is being phased out," Grodman clearly stated last May, "and is supposed to terminate entirely in November of this year." At this point, Bio-Reference has already spent an entire quarter and the first month of another exposed to the BlueCard restrictions instead of the partial quarter suggested by the excuse for its inaction.

With the company still waiting to quantify a hazard that has literally hammered other regional labs in recent months – and clinging to guidance that assumes no damage at all until the detection of a legitimate threat -- Bio-Reference looks a bit exposed, to state the obvious.

Even if Bio-Reference manages to avoid immediate downside by recording the revenue for its out-of-state BCBS claims in advance (a routine practice throughout the industry), the company should still witness a drop in collections and a rise in bad debt that would foreshadow imminent trouble. With Bio-Reference reportedly closing one of the labsthat conducts its sophisticated pathology tests, in fact, the company has already dropped a possible hint about slowing demand for those high-end services.

Nevertheless, Bio-Reference has practically guaranteed Wall Street that it can somehow remain immune to the relentless headaches that keep on pounding other players in the battered lab industry. Of course, that healthy prognosis started to look doubtful at least a month ago, when proposed Medicare cutbacks on expensive specialty tests proved even worse than most experts had feared. With labs already worried about a potential 20% dive in those rates, an influential Medicare carrier rattled the entire industry by not only recommending cuts far closer to 30% but also excluding a number of specialty tests from its coverage list altogether.

For some tests, Laboratory Economics emphasized, the cuts look remarkably worse. Take one of the tests that Bio-Reference markets through its GenPath specialty lab, for example. While GenPath currently charges $515.58 for that particular test, Laboratory Economics revealed, the lab would receive just $116.25 – collecting a mere 22% of its current fee – under the proposed formula.

Chances are, Bio-Reference hoped for a lot more than that. Regardless, Bio-Reference swiftly ruled out the potential need for adjustments to reflect the steep Medicare cuts.

“The guidance provided by the company in Q4F12 and for FY13 is based on the company’s understanding and assimilation of this information,” Bio-Reference assured TheStreetSweeper this week. “In addition, the company discussed the potential impact of molecular diagnostics reimbursements in prior earnings calls.”

Imagine the punishment that Bio-Reference would risk by actually dropping its own bombshell. Based on its dangerous silence, the company must have winced at the mere thought of that possible hit. In fact, as outlined in detail below, Bio-Reference has kept its mouth shut about several jarring developments that could blindside investors kept in the dark until now.

Blowing the Whistle

Technically, Bio-Reference did sound one rather weak alarm that could alert those shareholders industrious enough to comb through all of its regulatory filings.

When Bio-Reference issued its latest annual report about six weeks ago, the company offered its first major clue that (as widely suspected by its critics) government authorities have, in fact, questioned its billing practices. In a brand-new disclosure, totally absent from its past 10-K reports, Bio-Reference has suddenly confessed the following:

“The company has, from time to time, received subpoenas from state agencies and from the Office of the Inspector General of the U.S. Department of Health and Human Services seeking documents relating to its billing-related activities. (Moreover), the company may also be named from time to time in suits brought under the qui tam provisions of the False Claims Act and comparable state laws in which allegations may be made that the company has submitted or caused to be submitted false claims in connection with claims for payment from federal or state health programs …

“We believe we operate lawfully within these statutes,” the company repeated elsewhere as its standard defense. “However, we cannot predict if some of our practices may be interpreted as violating these statutes and regulations” by outside government authorities.

When pressed for details about these revelations, Bio-Reference promptly adopted a defensive – if somewhat radical – stand. Asked to describe the subpoenas, for example, Bio-Reference suddenly proclaimed that "the company has no knowledge of any government subpoenas about its billing practices” after all. Since its own 10K filing clearly states that Bio-Reference “has, from time to time, received subpoenas … seeking documents relating to its billing-related activities” – and even identifies the government agency that sent at least one of those demands by name -- the company has effectively disputed its very own statements.

That contradiction basically signals one of two possibilities. Either Bio-Reference bluntly lied to TheStreetSweeper when asked about the subpoenas. Or the company lied to the public at large when it added that new disclosure to its 10K filing – certified by its leaders as reliable -- for some inexplicable reason.

Taking a similar approach to questions prompted by its other brand-new disclosure, Bio-Reference proclaimed that it “has no knowledge about any whistleblower lawsuits against the company,” either. If so, Bio-Reference must have somehow overlooked the qui tam lawsuit – now readily available to the general public – that TheStreetSweeper easily located on its own.

Although Bio-Reference recently overcame that particular lawsuit, pursued for years by a New York physician who voluntarily dismissed the case because of a problematic technicality, the company apparently underwent a rather intensive government review by the time that it scored that lucky break. Even Dr. Arnold Berlin, the Brooklyn internist who actually filed the complaint, felt surprised when the FBI showed up to assist the crowd of government officials already investigating the “fraudulent billing scheme” that he suspected Bio-Reference of using to fleece “all of the various Medicare Advantage plans” throughout the country.

If his allegations resemble the truth, that government interest makes perfect sense. In a nutshell, his story goes something like this:

After fielding a visit from a pair of Bio-Reference sales representations, who informed him that their company had replaced giant LabCorp (NYSE: LH) as the preferred provider for a big New York-based Medicare Advantage carrier known as Elderplan, Berlin decided to go ahead and give the smaller lab a chance. Told that he could expect to save money after the change, Berlin felt stunned to discover that his lab costs actually more than doubled the following year instead. Understandably rattled, Berlin pored over his paperwork – comparing the lab tests that he had ordered with the fees that Bio-Reference had charged – and grew increasingly alarmed by the pattern that he saw.

While Berlin normally wanted nothing more than a standard metabolic profile, sold at a cheap packaged rate as a general rule, Bio-Reference had instead charged Elderplan for individual tests within that profile and then tacked on additional panels – which he never even ordered – to further inflate the bill. Struck by the curious billing system that Bio-Reference used from the very start, Berlin sensed that he had fallen victim to a much broader scam. Since Bio-Reference had systematically overcharged Elderplan for lab tests on his own patients, he reasoned, the company could have easily targeted other Medicare Advantage plans with its elaborate scheme as well.

The situation must have struck the Department of Justice as serious, since federal prosecutors kept on seeking extensions to review the case for years. Only after they identified Berlin – rather than Medicare itself – as the actual victim in this instance (due to the capitated nature of his Elderplan account) did they finally abandon the case and leave the doctor with little choice except to follow suit.

“They really investigated the hell out of it,” Berlin told TheStreetSweeper ahead of this report. “They even had the FBI involved … The reason it was dropped was because of the payment mechanism; they couldn’t prove that the government had sustained a loss.

“They felt they had a good case against Bio-Reference” otherwise, he assured. “I had all of the evidence right there.”

Hitting the Jackpot

Just months after Berlin filed his 2005 complaint, kept under seal until November of last year, Bio-Reference promptly rewarded one of the sales representatives who landed that account – and guided the doctor through its complex billing process – by promoting him and placing him in charge of training its aggressive sales team.

With that kind of money at his disposal, a comprehensive background report (subject to restrictions that prohibit redistribution) suggests, Fein could soon afford some truly spectacular toys. Barely a year after assuming his lucrative post, the report indicates, Fein splurged on a luxurious vacation home. Choosing a sub-tropical getaway that promised more sunshine than his 6,400-square-foot house back in New York, the report suggests, Fein shelled out $1.8 million for a beachfront Florida condominium located in fraud-riddled Boca Raton.

Thanks to a generous car allowance, records show, Fein has long traveled in high style as well. An obvious fan of Mercedez-Benz (since he has owned a string of them over the years), that background report indicates, Fein currently zips around in a late-model version with a sticker price just shy of the six-figure mark.

On occasion, however, Bio-Reference did encounter some noteworthy resistance from critical BCBS plans along the way. Go back more than a decade, when Bio-Reference first began generating a decent portion of its revenue (25%) from esoteric tests, for an early example. Within a year of that spike, as Grodman himself has since noted, the BCBS plan in New York – the largest market that Bio-Reference serves – literally tried to bury the company for good.

“I remember in 2002 that Empire, the New York Blue, was the first payer that went to, in essence, an exclusive contract for a preferred provider organization,” Grodman told other lab executives last May, when urging them to stage a futile effort to block the imminent BlueCard change. “The CEO said this to me through an intermediary: ‘Tell Grodman he’s finished. He’s done. The business is over. He’ll never survive.’

“That was 10 years ago,” he added. “They’re still saying it, and they’re saying it to a lot of us …

“If we’re shut out of the game before that change evolves, then we won’t be able to compete,” he emphasized. So “in any way you can, be a pain.”

“Overnight, you go from being an in-network laboratory with no co-pays and deductibles to an out-of-network laboratory with co-pays and deductibles,” Grodman complained months before BCBS enacted its nationwide policy. “The easier access that BlueCard afforded the patient will be gone … You simply will have no ability – no way, no mechanism – to bill, except to have the patient pay for it out of his or her own pocket.”

As one of those out-of-state BCBS policyholders herself, Diana Konrad never even wanted the fancy GenPath test that her insurance covered in the first place. A California photographer whose striking pictures appear in the likes of Vogue magazine, Konrad felt stunned when she saw the bill that resulted from her last routine exam. Since the actual visit came to $300, Konrad could not fathom why the bill for her lab work totaled three times that amount. Konrad would have remained oblivious to the entire situation, however, if GenPath had not pestered her for a copayment on top of the $800 that it had already charged her BCBS plan.

Confused that a pap smear could even cost that much, Konrad understandably wanted some answers. Under the care of Dr. Robert Biter in San Diego at the time, Konrad started by calling his office. Initially sensing a possible mistake, a staff member there examined her medical file and determined that, while Biter had indeed ordered a routine pap smear, GenPath had instead submitted a claim for a more elaborate test – screening for all sorts of sexually transmitted diseases without authorization – and then proceeded to stun Konrad even more by what she said next.

“She said, “I think the lab is regularly overcharging patients like this and, when they charge the insurance, they don’t return anything,’” Konrad declared when giving Biter a one-star rating (the lowest possible) in a review published on the Internet as a warning for the entire world to see. “Yet when I asked how can they keep doing business with them after this and told her it’s their responsibility to help me, she got really rude and pretty much told me to figure out things on my own …

“They finally persuaded the lab to waive the out-of-pocket fees, but are still keeping what they’ve stolen from my insurance. This is wrong on many levels and could happen to you. I’m sure there are better doctors who would take action with their contracting lab, if it tried pulling this off with their patients.”

In a controversy that originally seemed to explode out of nowhere, past newscoverage shows, Biter found himself suddenly barred in May of 2010 from delivering babies at Scripps Encinitas Hospital – where he had practiced for years – despite his cult-like following. With Biter suggesting that Scripps had punished him for his low rate of lucrative caesarean sections, understandably outraging his loyal fans, the doctor soon regained his former access to Scripps only to then resign from the hospital altogether.

Despite the lingering questions triggered by that messy departure, Biter continued to enjoy a groundswell of support from staunch defenders thrilled with his plans to establish a private birthing center of his own. With that facility still unfinished by last spring, however, Biter reportedly convinced a couple to elect for a home delivery that dragged on for 22 hours before finally ending in tragedy – the baby stillborn – and effectively destroying his career. His medical license now suspended indefinitely (following a previous two-month suspension last year), recordsshow, Biter has basically run out of options and run out of support from his former cheerleaders as well.

For its part, Bio-Reference should probably go ahead and cross that dependable client off of its list (if it hasn’t done so already) and look elsewhere for $800 lab tests that can boost its performance instead.

By the time that the Feds indicted those 36 suspects (including ringleaders with mobster-like nicknames such as “Russian Mike,” “Fat Mike,” “Skinny Mike” and “KGB”), the group had allegedly spent at least five years systematically fleecing insurers and carefully laundering the proceeds – estimated at more than $100 million – that resulted from its brazen scam.

“Today’s charges expose a colossal criminal trifecta, as the fraud’s tentacles simultaneously reached into the medical system, the legal system and the insurance system, pulling out cash to fund the defendants’ lavish lifestyles,” government authorities proclaimed when announcing their gigantic crackdown. “Our undercover officers were treated like thousands of other ‘patients’ receiving therapy, tests and medical equipment they didn’t need … The criminal enterprise, while it lasted, was obscenely profitable.”

Far from a stranger to the criminal underworld, as documented in an extensive report published by TheStreetSweeper back in late 2011, Bio-Reference actually developed a regular habit of partnering with crooks as a young company and even keeps a convicted felonstationed in its own executive suite to this very day. Without that heavy baggage, Bio-Reference might look more like an innocent healthcare provider that simply happened to attract a string of bogus accident victims to its labs by sheer coincidence. But as a company haunted by persistent rumors about lingering ties to organized crime -- and derided by its critics as the “Mafia Lab” -- Bio-Reference tends to raise a few extra red flags when it lands business from suspected con artists.

Bio-Reference provided little color about this aspect of its business itself.

When presented with multiple questions seeking details about its involvement in this fraud-infested corner of the medical world – the number of lawsuits its faces, the reason behind that volume, the sources of the referrals, the value of the resulting claims, etc. – Bio-Reference elected to completely ignore most of the inquiry and vaguely address the one or two that remained. The following represents its comments in full:

“The company processed in excess of 7 million patients in 2012,” Bio-Reference stated. “Of that number, an insignificantly small number of claims are reimbursed by no-fault insurance policies. Nonetheless, the company has a policy in place covering such services.”

Still left with a lot of unanswered questions, TheStreetSweeper decided to at least sniff around for additional clues. Unfortunately, upon contacting the attorneys hired to represent the car insurers who filed the actual lawsuits, TheStreetSweeper discovered that they operate under confidentiality agreements that prevent them from publicly discussing their cases. After supplementing the lawsuits with some useful information that now included a few interesting name – one of them identified as the Bio-Reference sales representative who might actually cover the Brighton Beach area that has spawned so much no-fault insurance fraud – TheStreetSweeper then sought the assistance of a specialized expert in the field.

“I do find lots of references – lots of references – to the names that you have provided and to BRLI in the claims database,” Scafidi reported back to TheStreetSweeper earlier this month. “What I cannot determine from my limited access to these files is if any of this information is at all nefarious or if there are any ongoing investigations involving any of these folks. Usually, where there’s smoke, there’s fire, but I am prohibited from accessing the ‘meat’ of the data that is available to our investigators …

“If past is any indicator, these folks have not likely been rehabilitated,” he advised. So “I’d follow your instincts on this one.”

* Important Disclosure: Prior to the publication of this investigative report, TheStreetSweeper established a short position in Bio-Reference (BRLI) and stands to profit on any future declines in the share price.All told, TheStreetSweeper has sold a total of 126,157 shares of BRLI short at an average price of $25.98 at the present time. Going forward, TheStreetSweeper may choose to adjust the size of that investment -- by increasing, decreasing or covering the short position that it currently holds -- and will promptly disclose the details of any future transactions as those trades occur.

As a matter of policy, TheStreetSweeper prohibits members of its editorial team from taking financial positions in any of the companies that they cover. To contact Melissa Davis, the primary author of this story, please send an email to editor@thestreetsweeper.org.